Akhtari‑Zavare et al.

SpringerPlus (2015) 4:692

DOI 10.1186/s40064-015-1491-8

RESEARCH Open Access

Barriers to breast self examination

practice among Malaysian female students: a
cross sectional study
Mehrnoosh Akhtari‑Zavare1*, Muhamad Hanafiah Juni2, Irmi Zarina Ismail3, Salmiah Md Said2
and Latiffah A. Latiff2

Abstract 
Introduction:  Breast cancer is the most frequent cancer and the second reason of cancer deaths among woman
worldwide, including Malaysia. The objective of this paper is to assess the practice of breast self-examination (BSE)
and identify the barriers of BSE practice among undergraduate female students in Malaysia.
Methods:  A cross-sectional study conducted among 810 female undergraduate students in Klang Valley, Malaysia
between April–Jun 2012. Data was collected via self-administered questionnaire which was developed and pre-tested
for this study.
Results:  The majority of respondents were Malay 709 (95.6 %) and single 719 (96.9 %) with a mean age of 21.7 (1.1).
Only hundred eleven (15 %) of the participants had a family history of breast cancer. 70.5 % of the respondents do not
practice breast self-examination, 70.5 % do not know how to do it, 64.7 and 61.5 % reported no symptoms of breast
cancer and worries to detect breast cancer, respectively. Univariate analysis showed that age, marital status and per‑
sonal history of breast disease were statistically associated with the practice of breast self-examination.
Conclusion:  In this study, a high percentage of respondents were aware of breast cancer but do not perform breast
self-examination. Knowledge, socio-cultural and environmental factors were identified as barriers; so it is recom‑
mended that knowledge among the public about breast cancer and promotion of public breast health awareness
campaigns through the media should be carried out.
Keywords:  Breast cancer, Breast self-examination, Barriers, Young female, Malaysia

Background (Youlden et al. 2014). Malaysia being one of the countries

Nowadays, breast cancer is one of the most frequently
detected cancers and is the major cause of death among
women worldwide (Loh and Chew 2011). Based on the
National Cancer Registries in Asian countries, varia-
tion for crude incidence rate of breast cancer is 21.3 per
100,000 population in Jordan (Petro-Nustus and Mikhail
2002), 21.4 per 100,000 in Iran (Sadjadi et al. 2009), 24.1
per 100,000 in Turkey (Nahcivan and Secginli 2007) and
52 per 100,000 population in Japan and South Korea
*Correspondence: akhtari.mehrnoosh@gmail.com
1
Cancer Resource and Education Center, Universiti Putra Malaysia,
43400 Serdang, Selangor, Malaysia
Full list of author information is available at the end of the article
in the Asian region affected with modernization is heav-
ily burdened with the problem, with breast cancer occur-
ring in 34.86 per 100,000 population (Hisham and Yip
2004).
In Malaysia, breast cancer is the most common cancer
and the first cause of death from cancer among women.
According to the National Cancer Registry, there were
3525 female breast cancer cases registered in Malaysia,
and 1 out every 19 Malaysian women has the chance of
getting breast cancer during their lifetime (National Can-
cer Registry 2006).
Early detection of breast cancer can reduce its morbid-
ity and mortality (Avci 2008). Mammography, clinical
breast examination and breast self-examination (BSE) are

© 2015 Akhtari-Zavare et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International
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Akhtari‑Zavare et al. SpringerPlus (2015) 4:692
considered effective methods for early detection of breast
cancer (Avci 2008). There are arguments surrounding
the efficacy of BSE. A large well-conducted randomised
controlled trial among 266,064 textile workers in Shang-
hai which teaching women to perform BSE showed dis-
tribution of tumor size and stage at diagnosis as well as
mortality rate for breast cancer was nearly same between
women in the two arms of the trial (Thomas et al. 2002).
With these result, numerous organisations including US
Preventive Service Task Force (2009), the Canadian Task
Force on Preventive Health Care (Baxter 2001) deter-
mined that breast self-examinations no more benefit for
women.
Although BSE alone is not sufficient for early detection
of breast cancer, but it is still an important screening tool
for early detection of breast cancer in developing coun-
tries, because it is cheap, widely available, and does not
require complex technical training (Giridhara et al. 2011).
Overall, by performing regular BSE, women familiar with
the structure of normal breasts will be motivated to attend
screening clinics for mammography and clinical breast
examination (Giridhara et al. 2011; Tavafian et al. 2009).
The Malaysian Ministry of Health has been promoting
BSE and annual breast examinations by trained health
workers as part of breast health awareness campaigns
since 1995 (Ministry of Health Malaysia 1999). While
the majority of women seem to be aware of breast self-
examinations, yet many still do not know how to perform
it properly (Soyer et al. 2007). Studies conducted among
different groups of women in Malaysia showed that
monthly BSE practice ranged from 19.6 to 36.7 %, respec-
tively (Akhtari-Zavare et  al. 2015; Rosmawati 2010).
Although early detection of breast cancer can increase
the survival rate, many women miss early detection due
to lack of knowledge and information about breast health
awareness (Avci 2008). Also, as the American Cancer
Society has proven, if breast cancer is detected at an
early stage (stage I–II), a 100–93  % survival rate can be
achieved, and this rate decreases to 72–22  % if breast
cancer is diagnosed at later stages (III–IV) (American
Cancer Society 2013).
Many investigators have tried to determine the factors
that affect women’s practice of BSE, because these factors
are essential to plan effective intervention programs to
improve BSE practice (Tarawneh and Attiyat 2013; Gumus
et  al. 2010). Current literature showed many barriers to
BSE practice, which include social and cultural perceptions
of breast cancer and breast self examination, socio-demo-
graphic factors, level of knowledge, and awareness (Hisham
and Yip 2003; Rasu et al. 2011). Result of study done (Bit-
Na et al. 2012) among Korean women shows (31.7 %) did
not know how to do it, they would never have breast cancer
(26.3 %), not effective for detecting breast cancer (17.1 %)
Page 2 of 6
and fear of detecting breast cancer (5.3  %). In Malaysia,
there are few research done on the elimination of barriers
of breast cancer awareness among young women (Hadi
et al. 2010); because young women believe that they are not
at risk of getting breast cancer (Johnson and Dickson-Swift
2008). The emergence of breast disease and the subse-
quent development of cancer tend to be more aggressive in
young patients compared with breast cancer progressions
in the older population (Johnson and Dickson-Swift 2008).
Also, there is a lack of knowledge about the benefits of BSE
among young women. For this reason, the aim of this study
is to identify the barriers of BSE practice among undergrad-
uate female students in Malaysia.
Methods
Study design and sampling method
A cross-sectional study was carried out among female
undergraduate students in public universities in Klang
Valley, Malaysia, between April and Jun 2012.
A multi-stage random sampling method was used to
select students from public universities. A total of 810 stu-
dents met the inclusion criteria and had gave informed
consent to participate in the study. The inclusion criteria
for this study was; age 20 years old and above, no history of
breast cancer, and not pregnant or breastfeeding. This study
obtained approval from the Ethical Committee of Universiti
Putra Malaysia and the Ministry of Higher Education.
Instrument
Data was collected via self-administrative a question-
naire which was developed by the researchers based on
an extensive review of the literature. The content validity
was evaluated by three expert from Community Health
Department at Universiti Putra Malaysia to examine each
item for congruence. The reliability of the questionnaire
was determined by using test–retest reliability conducted
among 80 female undergraduate students at Universiti
Putra Malaysi not included in the study, and distributed
in both English and Bahasa Malaysia language. The value
of kappa for categorical data ranged between; breast can-
cer awareness (0.80–0.90), Breast cancer and BSE aware-
ness (0.70–0.97). The value of intra-class correlation
coefficient (ICC) for barriers of BSE practice (continuous
data) was (0.70–0.80).
The questionnaire obtained information on respond-
ents’ socio demographic characteristics, awareness of
breast cancer and BSE, barriers for BSE practice, practice
of BSE and source of information.
Socio demographic variables included: age, race, mari-
tal status, family income, family history of breast cancer
(yes/no), personal history of breast disease (yes/no), hor-
monal drug usage (yes/no) and check the breast by doc-
tor (yes/no).
Akhtari‑Zavare et al. SpringerPlus (2015) 4:692 Page 3 of 6

Breast cancer and BSE awareness questions (yes/ Table 1 Demographic and  health characteristics of  the
no response) included: “Have you ever heard about participants (n = 742)
breast cancer?”, “Have you ever heard about BSE?”, Variables No %
“Do you know how to do BSE?”, and “What is the age
of BSE?”. Age (mean ± SD) 21.7 ± 1.1
The practice of BSE was assessed by asking respondents Marital status
if they had ever done BSE (yes/no), and the frequency of  Single 719 96.9
doing BSE (once a month, occasionally and others).  Others 23 3.1
The section about barriers for BSE practice had seven Ethnicity
questions and respondents had to either “agree” or Malay 709 95.6
“disagree”.  Non-Malay 33 4.4
 Family income (Mean ± SD) 4730.3 ± 2122.2*
Analysis Family history of breast cancer
All data was analyzed using PASW version 20.0 and a p  Yes 130 16.4
less than 0.05 was considered as a level of significance.  No 662 83.6
Descriptive statistics (mean and SD) were obtained for all Personal history of breast disease
the variables in the study. Chi-square analysis was used  Yes 11 1.5
to determine the relation between categorical variables  No 731 98.5
and BSE practice, and an independent sample t test was Hormonal drug usage
made for continuous data (age and family income).  Yes 40 5.1
 No 752 94.9
Results Check your breast by doctor
Respondent rate  Yes 73 0.5
A total of 810 female students were selected as the sam-  No 705 95.0
ple of the study. However, 68 respondents (8.3 %) refused
to participate. The respondents’ rate derived in this study
was 91.6 %. Among those who practice BSE, most of them practice
BSE occasionally at 96 respondents (50.8 %) and only 59
Socio‑demographic characteristics of the respondents (31.2  %) respondents practice BSE once a month. The
The mean (SD) age of respondents was 21.7 (1.1) and majority (50.2  %) stated the reason for performing BSE
ranged between 20 and 25  years old. The majority of was to check their breast regularly, while 57 (30.1  %)
them were Malay 709 (95.6  %), single 719 (96.9  %) and had family history of breast cancer, 27 (14.2 %) had per-
with monthly incomes of RM 4730.3 (2122.2). Family his- sonal histories of breast diseases and 10 (5.2 %) had other
tory of breast cancer was reported by 111 (15.0 %) of the reasons.
respondents while 11 (1.5 %) had histories of breast prob- There were statistically significant relationships
lems (Table 1). between those practicing BSE and those who did not
practice BSE with age (t = −3.21, p = 0.001), marital sta-
Awareness of breast cancer and knowledge of BSE tus of respondents (χ2  =  8.91, p  =  0.003) and personal
Seven hundred thirty-eight (99.5  %) respondents have history of breast disease (χ2 = 4.97, p = 0.02). There were
heard about breast cancer. Five hundred thirteen (69.1 %) no statistical differences between performing BSE with
had heard about BSE, but only 289 (38.9 %) respondents the rest of the variables.
know how to do BSE. Regarding the age to begin BSE,
only 303 (40.8) knew about it. Among those 513 who Barriers towards BSE practice
had heard about BSE, the main source of information A total of 533 (74.5  %) respondents who did not prac-
was printed media (newspapers, brouchures) with 270 tice BSE had nominated barriers for not performing it.
respondents (52.6  %), followed by information obtained The most common causes for not performing BSE were:
from medical health personnel at 150 respondents I don’t know how to do it at 390 respondents (70.5 %); I
(29.2 %), media at 60 respondents (11.7 %) and others at don’t have any symptoms at 358 respondents (64.7  %);
33 respondents (6.4 %) (Table 2). and I have worries in detecting breast cancer at 340
respondents (61.5  %). About 299 (54.1  %) respondents
Practice of BSE said that “doing BSE will take too much time” and 294
Although 738 (99.5  %) of the participants have heard (53.2  %) respondents do not have enough privacy to do
about breast cancer, only 189 (25.5  %) performed BSE. BSE (Table 3).
Akhtari‑Zavare et al. SpringerPlus (2015) 4:692
Table 2  Awareness of breast cancer and knowledge of BSE
(n = 742)
Statements Yes
no (%)
Ever heard about breast cancer 738 (99.5)
Ever heard about BSE 513 (69.1) 229 (30.9)
Know how to do BSE 289 (38.9) 453 (61.1)
The age of BSE is starting from 20 years old 303 (40.8) 439 (59.2)
BSE is important for women to know how their 260 (35.0) 482 (65.0)
breasts normally feel
Table 3  Barriers towards BSE practice among respondents
(n = 742)
Statements No
I don’t know how to do it 390
Doing BSE will take too much time 299
I don’t have any symptoms 358
I am scared of being diagnosed with breast cancer 340
I don’t have enough privacy for BSE practice 294
I don’t feel it is necessary 317
BSE will be embarrassing to me 334
Discussion
This study was conducted in order to examine BSE prac-
tice and barriers to BSE practice among Malaysian female
students. In the current study, 69.1  % respondents were
informed about breast self-examination. This is similar
with the results of a previous study done in University of
Gezira, Sudan (Abdelrahman and Yousif 2006) and incon-
sistent with the findings of a study from Malaysia (Al-Dubai
et al. 2012) which found that 91 % of women were aware of
breast self-examination. In this study, 189 (25.5 %) respond-
ents perform BSE, but a small number of students (31.2 %)
perform BSE once a month. The main reason for practic-
ing BSE was to check their breast regularly. Similar to our
findings, a study from Iran reported that 100 (26 %) women
practice BSE, and most of them 53 (13.8  %) practice BSE
occasionally (Akhtari-Zavare et  al. 2014). This poor prac-
tice may be due to young women’s perceptions that they are
healthy and thus do not need to perform a BSE.
Additionally, amongst this study samples, the most
common source of information on BSE were printed
media (newspapers, brochures) followed by information
from medical health personnel. Similarly, in a study done
by Al-Dubai et  al. (2012) reported that newspapers and
magazines were the main source of information on BSE.
But, this finding is inconsistent with a previous study
from Iran (Akhtari-Zavare et al. 2014) and Malaysia (Al-
Naggar et al. 2011) who reported that television was the
most common source of information.
Page 4 of 6
Based on the results of this study, age, marital status
and personal history of breast disease effect BSE prac-
No tices (p  <  0.05), but no association was found among
no (%) those who practice BSE and the rest of the variables.
This result is similar with the findings of other stud-
4 (0.5)
ies done by Redhwan et  al. (2011) among female uni-
versity students in Malaysia and Al-Azmy et al. (2013)
among women attending primary health care clinics
in Kuwait. There have been studies with conflicting
results as well. While finding of studies done in Tur-
key (Doganer et al. 2014) and Kuwait (Al-Azmy et al.
2013) claimed that family history of breast cancer
was related to performing BSE, another two studies
revealed no significant relationship between BSE per-
formance and family history of breast cancer (Tava-
% fian et al. 2009).
70.5 In this study, the main reasons for not practicing BSE
54.1 were “don’t know how to do BSE” (70.5  %); followed by
64.7 “don’t have any symptoms” (64.7 %). Many young women
61.5 believe that breast cancer affects only older women and
53.2 thus, they are not at risk for getting breast cancer (Avci
57.3 2008). Also, lack of knowledge about how to do BSE
60.4 among young Malaysian women have been due to inade-
quate education programs about breast health awareness
for this target population. Consistent with our results,
in many studies, women had mentioned that they don’t
know how to do BSE (Redhwan et al. 2011; Tavafian et al.
2009) and they did not believe that they are at risk for
getting breast cancer (Redhwan et al. 2011).
Others mention barriers towards breast self-exami-
nation practice such as “scared of being diagnosed with
breast cancer” and “BSE will be embarrassing to me”.
Similar to previous studies in Malaysia (Redhwan et  al.
2011), Turkey (Avci 2008) and Iraq (Alwan et  al. 2012)
these fears may be a result of wrong perception of women
on being diagnosed with breast cancer. Consequently,
providing health educational programs about breast can-
cer and the significance of breast self-examination prac-
tices can reduce these worries due to wrong beliefs and
motivate them to practice breast self-examination.
In the current study, “not enough privacy for BSE prac-
tice”, “not necessary” and “BSE takes too much time”
were other barriers for performing BSE among young
women in Malaysia. Providing breast health education
programs among young women may help change the
negative barriers towards breast self-examination and
empower women to participate actively in making deci-
sions regarding their health.
Limitation of study
Since this study has been done among female undergrad-
uate students, the findings cannot be generalized to the
whole population in Malaysia.
Akhtari‑Zavare et al. SpringerPlus (2015) 4:692
Implication for practice
Although there is no evidence that BSE lowers mortality
from breast cancer, it should not be promoted to effec-
tively detect breast cancer tumors in women. Women are
at risk of harm from BSE including unnecessary breast
biopsies, imaging tests and emotional duress (Hackshaw
and Paul 2003).
Breast self-examination (BSE) might still be an impor-
tant tool to improve breast awareness. Women are encour-
aged to take responsibility for their own health by taking
opportunities such as during bathing or dressing to become
familiar with their breasts at different times of the month
and with age, looking and feeling for any changes from nor-
mal, and reporting any obvious changes promptly. There-
fore, appropriate educational interventions are needed to
encourage women to engage in regular breast awareness as
well as to practice BSE (Bit-Na et al. 2003).
Conclusion
In conclusion, the rate of BSE practice among young
females in Malaysia is low and there are some barriers for
doing BSE among this group. But as a this group is an edu-
cated group and has positive attitudes toward learning BSE
from practice instructors, it is recommended to promote
public breast health awareness campaigns through the
media. Also, it is mandatory to establish or improve nation-
wide policy guidelines to increase the dissemination of
information about breast cancer, the importance of breast
self examination and other screening methods for control-
ling breast cancer among young females in Malaysia.
Authors’ contributions
MA-Z, MHJ, IZI designed the study. MA-Z and SMS analyzed the data. MA-Z
and LAL wrote the manuscript. All authors read and approved the final version
of the manuscript.
Author details
1
 Cancer Resource and Education Center, Universiti Putra Malaysia, 43400 Ser‑
dang, Selangor, Malaysia. 2 Department of Community Health, Faculty of Medi‑
cine and Health Science, Universiti Putra Malaysia, 43400 Serdang, Selangor,
Malaysia. 3 Department of Family Medicine, Faculty of Medicine and Health
Science, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia.
Acknowledgements
This work was supported by University Putra Malaysia through the Graduate
Research Fellowship. We acknowledge all the students who took part in the
study.
Competing interests
The authors declare that they have no competing interests.
Received: 17 March 2015 Accepted: 30 October 2015
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